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SAN JOAQ13IN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S. �. � �, �� L ;.�/` CENSUS TRACT <br /> Owner's Name ,.� u C A wc)4 Yom° Phone <br /> r <br /> Address J o � G`� City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION %j <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel, Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: "4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4.PUMP REPLACEMENT: State Work Done .�to V / T�';2 �frL�. <br /> PUMP -,REPAIR: / / State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL VOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND 4,,FIE4L,. INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I % _...-.. <br /> APPLICATION ACCEPTED BY � �, �� w- �t_ ,. /..-, DATEa ', <br /> ADDITIONAL COMMENTS: r' <br /> PHASE II GROUT INSPECTION` PHAS9 11_11,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE%' DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />